Malnutrition: nutritional rehabilitation and monitoring — structured clinical encounter

Station 1 — recognition and disposition

Asked for my assessment, I explain that a weight-for-height z-score below minus three together with a MUAC below 115 mm defines severe acute malnutrition, and that either criterion alone is sufficient. The decisive clinical finding is his refusal of food, which demonstrates loss of appetite and places him in the complicated SAM group, so he needs inpatient stabilisation rather than outpatient ready-to-use therapeutic food. I would check a bedside glucose, assess for hypothermia and infection, and admit him. [1]

Station 2 — the immediate threats

Asked what I would treat first, I state that the immediate threats in complicated SAM are hypoglycaemia, hypothermia, dehydration, infection and electrolyte derangement, and these are addressed before any weight gain. I would check and treat a low glucose, keep the child warm, give empirical broad-spectrum antibiotics because infection is often occult, correct the routine potassium and magnesium deficits, and give thiamine before the first feed. Iron would be withheld in the stabilisation phase because early iron can worsen infection. [11] [1]

Station 3 — the feeding phases

To rehabilitate him I would follow the WHO phased pathway. I would start F-75, the stabilisation formula at about 75 kcal per 100 mL, given as small frequent feeds at roughly 100 kcal per kg per day, with the deliberate aim of stability rather than weight gain. Once he is stable, hungry and free of complications, I would transition cautiously over a few days and then switch to F-100 or ready-to-use therapeutic food at 100 to 200 kcal per kg per day to drive catch-up growth, watching for heart failure as the feed becomes energy-dense. [1] [8]

Station 4 — preventing refeeding syndrome

Asked how I would keep the refeeding safe, I describe the monitoring bundle. I would check phosphate, potassium and magnesium at baseline and at least every twelve hours in the first days of feeding, because refeeding syndrome develops silently and a falling phosphate is the earliest biochemical signal, and a normal admission phosphate does not exclude it. I would give thiamine before feeding, correct low phosphate and potassium, and slow the feed if the electrolytes fall. I would watch for the fluid overload and heart failure that mark the cardiac complication. [3] [6]

Station 5 — discharge and preventing relapse

Finally I describe my discharge and follow-up plan. I would discharge him only when he is eating well, gaining weight, free of oedema and medically stable, and I would link the family to a clear follow-up plan with periodic weight and MUAC checks until sustained recovery. I would address the underlying driver of his malnutrition, whether food insecurity, feeding difficulty or illness, because relapse usually means the child returned to the same circumstances. The targets confirming recovery are sustained weight gain, a rising MUAC out of the danger zone, and no relapse on review. [4] [11]